2017 Health Insurance MarketPlace - Molina Healthcare€¦ · They connect individuals to all the...

2017 Health Insurance MarketPlace

TANF 80%

Jackson

Calhoun

Franklin

Gadsden

Gulf

Leon

Wakulla

Alachua

Baker

Bay

Brevard

Broward

Charlotte

Citrus

Clay

Collier

Dade

De Soto

Dixie

Duval

Escambia

Flagler Gilchrist

Glades

Hamilton

Hardee

Hendry

Hernando

Highlands

Hillsborough

Holmes

River

Jefferson

Lafayette

Lake

Lee

Levy

Madison

Manatee

Marion

Martin

Monroe

Okaloosa

Okeechobee

Palm Beach

Pasco

Polk

Putnam

St. Johns

St. Lucie

Santa Rosa

Sarasota

Seminole

Sumter

Suwannee

Taylor Union

Volusia

Walton

Washington

Liberty

Orange

Osceola

Nassau

Bradford

Columbia

Indian

Pinellas

Marketplace Service Area

2016:

3 Counties:

Broward, Miami-

Dade, Palm Beach

2017:

8 Counties:

Broward, Duval,

Hillsborough, Miami-

Dade, Osceola,

Pinellas, Palm

Beach, Polk

Counties in BOLD are Effective 01/01/17

Affordable Care Act (ACA) Overview

• The Affordable Care Act

(ACA) was passed in March of

2010 and due to the number

of provisions included in the

ACA, it is not expected to be

fully implemented until 2020.

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• Under the ACA, an individual mandate requires

individuals who do not have employer sponsored

coverage, and do not qualify for Medicare or Medicaid,

to purchase insurance coverage or pay a penalty.

Note: Individuals may be exempt from penalty for reasons of

religion or financial hardship as accepted by the Internal

Revenue Service (IRS).

• As a result of the individual mandate, the ACA created

the Health Insurance Marketplace (also known as Health

Insurance Exchange).

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Additional Provisions include but are not limited to:

• Insurers cannot deny coverage due to pre-existing

conditions.

• Individuals of the same age and geographical location

must be offered the same premium price regardless of

gender or pre-existing conditions (excluding tobacco

use).

• Coverage is no longer limited by annual and lifetime

dollar maximums.

• Children may remain covered under their parents

insurance until age 26.

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Health Insurance Marketplace

Health Insurance Marketplaces are state or

federally governed websites that are designed

to provide an affordable alternative to buying

coverage directly from private insurers.

In Florida individuals use the Federal

Marketplace located at:

www.healthcare.org

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http://www.healthcare.org/

Health Insurance Marketplace

They connect individuals to all the participating, private

insurers in an individual’s area and with one application

submission, eligible individuals can:

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• Determine if they qualify for

reduced costs through the

Advanced Premium Tax

Credit (APTC).

• Compare coverage options

for participating insurers.

• Select a plan to enroll in.*

*Members may not yet directly enroll on molinahealthcare.com, however, members may request a quote and a licensed agent will contact the member to assist.

Molina Marketplace Website

Members with questions

regarding changes to their

Molina Marketplace plan,

for the 2017 year, should be

directed to:

www.molinahealthcare.com

To view information on

state-specific Molina

Marketplace plans, they will

first need to choose a state

and language and select

submit to proceed.

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Eligibility Qualifications

In order to qualify for Marketplace, the potential member has to meet the following conditions:

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• Must be a U.S. Citizen or legal immigrant.

• Must not be eligible for Military coverage or public coverage including Medicaid, CHIP and Medicare.

• Cannot be currently incarcerated.

Eligibility Determination

There are only four eligibility determination outcomes:

• Eligible to purchase Marketplace coverage through a

Qualified Health Plan.

• Eligible to purchase Marketplace coverage through a

Qualified Health Plan and receive subsidies.

• Eligible for Medicaid on the basis of Modified Adjustment

Gross Income (MAGI).

• Eligible for Medicaid but not on the basis of MAGI (ex.

people with disabilities).

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Eligibility Rules

Florida Eligibility Rules

Dependent Age max 26

Student Age max 30

*Newborn Coverage Period

(including DOB)

31 days

Adopted Newborn Coverage

Period (including placement date)

31 days

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Newborn and Adopted Child

Eligibility Rules

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• If the member enrolls the newborn child within 31 days of birth, no

additional Premium will be charged for the first 31 days. If the member

does not enroll the newborn child within 31 days of birth, but enrolls

the child within 60 days of the birth, the child will be covered from the

date of birth. The member will be required to pay Premium for the

child from the date of birth.

• If a member adopts a child or a child is placed with a member for

adoption, then the child is eligible for coverage. The child can be

added during the open enrollment period, within 60 days of the child’s

adoption or within 60 days of the child’s placement for adoption. The

child’s coverage shall be effective on the date of adoption,

placement for adoption or as otherwise determined by the

Marketplace, in accordance with applicable state and federal laws.

Molina Marketplace ID Card

Two numbers on Molina

Marketplace ID Cards:

• Member ID* which is

the unique ID for each

member of the family.

• Subscriber ID which is

the unique number

assigned to the family.

*This is the number the providers would use to bill Molina for services

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Verifying Member Eligibility on Web-

Portal

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After logging in:

• Select “Member Eligibility”


Portal

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Member Search: • Enter Member ID or • Member First and Last

Name and Date of Birth

Select “Search for Member”


Portal

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Member Information will reflect member’s:

• Name • Date Of Birth • Mailing Address • Member ID Number

Select “Enrollment Information” to see details of member enrollment.


Portal

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Enrollment Information will reflect:

• Enrollment Plan • Enrollment Status • Effective Date • Health Plan ID • Subscriber ID

Links to Member’s:

• Summary of Benefits • Evidence Of Coverage

(EOC) • Benefit Co-Pay Summary

Amount

Enrollment and Coverage Dates

The coverage date depends on the day the member enrolled and

makes the first premium payment, also known as a binder payment.

Enrollment Date Coverage is effective*

On or before December 15, 2016 January 1st, 2017

Between the 15th and 31st of December February 1st, 2017

Between the 1st and the 15th of January February 1st, 2017

Between the 16th and the last day of January

February 15th March 1st, 2017

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*Key Point* Eligibility is not automatically started on the first of the next month

1. Bronze, Silver, and Gold Plans Offered

2. Silver 100-150 Plans have the lowest cost sharing to attract

target market

3. All covered services that have cost sharing accrue to the

Annual Out-of-Pocket Maximum

4. Extensive coverage of Preventive Care services at no

charge across all metal levels

5. Family Planning – no charge for counseling, birth control,

voluntary sterilization

Key Florida Marketplace Product Points

1. Options Bronze and Options Silver Plans Offered Only

2. CMS designed program

3. New for 2017

4. CMS now calls them “Simple Choice” plans

5. Other issuers offer these exact same plan designs, so that

members have a new way to comparison shop

6. Administered exactly the same as the other plans. The only

difference is cost-sharing amounts, deductible, and

OOPM

7. Watch out for plans with similar names, such as “Silver 100”

and “Options Silver 100”

Molina Marketplace “Options” Plans

CMS Standardized Options Bronze –

• CMS Standardized Options Plan waives Deductible

for Only First Three Primary Care or Other

Practitioner Office Visits, all Outpatient MH/SA

Services, Preventive Services, Preventive Drugs,

Pediatric Vision, Generic Drugs

Office Visit Cost Shares and Coinsurance are much

higher than Molina Bronze


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Silver Plan Benefit Driver

CMS Standard

Silver (Options)

Molina FFM

Silver

Silver 250% FPL Deductible Higher Lower

OOP Max Higher Lower

PCP Higher Lower

SPEC Higher Lower

Coinsurance Lower Higher

Generic Rx Even Even


OOP Max Even Even

PCP Higher Lower

SPEC Higher Lower


Generic Rx Even Even


OOP Max Lower Higher

PCP Even Even

SPEC Lower Higher

Coinsurance Even Even

Silver 100% FPL Deductible Higher None

OOP Max Even Even

PCP Higher Lower

SPEC Higher Lower


Generic Rx Higher Lower

CMS Standardized Options

Silver plans have:

Higher Deductibles,

PCP and Specialty

Copays

Molina FFM Silver Plans are:

Positioned with

minimal changes

Lower overall Out of

Pocket costs

Will be attractive

alternatives for our

target population


CMS Standardized Options Silver Plan Comparison

Enrollment Assistance

• Only licensed agents can advise / recommend / suggest

plans to prospective members.

• Member Service Agents can

answer questions regarding

current plans for existing

members.

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Special Enrollment – Exceptions

The Marketplace must allow

qualified individuals and

enrollees to enroll in a

Qualified Health Plan (QHP) or change from one QHP to

another as a result of a

qualifying event.

• 31 days to report the

qualifying event

• 60 days from the

qualifying event to select

a QHP

Special Enrollment Event

Loss of minimum essential coverage

Gaining or becoming a dependent

Gaining lawful presence

Enrollment errors of the Marketplace

Material contract violations by QHP

Gaining or losing eligibility for premium

tax credits or cost sharing reductions

Relocation resulting in new or different

QHP selection

American Indians and Alaska Natives

(AI/AN) may enroll in a QHP or change

from one QHP to another one time per

month

Exceptional circumstances

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Contact information for:

Molina Healthcare and Healthcare.gov

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Marketplace Contact Information

Molina Healthcare of Florida

Marketplace Providers:

Telephone: (855) 322-4076

TTY: (800) 955-8771

www.molinahealthcare.com Healthcare.gov

Telephone: (800) 318-2596

TTY: (855) 889-4325

www.healthcare.gov

http://www.molinahealthcare.com/

http://www.healthcare.gov/

Marketplace Benefit Types

There are two types of Benefits covered under

Marketplace:

• Essential Health Benefits (EHB) are benefits that the ACA requires all Qualified Health Plans to provide.

Essential Health

Benefits

• Value Added Benefits are not required by the ACA nor any other regulative authority and are considered a “selling point” to encourage members to enroll with Molina.

Value Added Benefits

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All Qualified Health Plans (QHP), must include the following ten

categories of Essential Health Benefits (EHB) defined by ACA:

1. Ambulatory Patient Services.

2. Emergency Services.

3. Hospitalization.

4. Maternity & Newborn Care.

5. Mental health and substance use disorder services,

including behavioral health treatment.

6. Laboratory Services.

Marketplace Required Benefits

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All Qualified Health Plans (QHP), must include the following ten

categories of Essential Health Benefits (EHB) defined by ACA:

7. Preventive and wellness services, and chronic disease

management.

8. Pediatric Services, including Vision and Dental Care.

• Molina is not required to offer pediatric dental

coverage if it is available via the Marketplace

through Standalone Dental Plans.

9. Rehabilitative and Habilitative Services.

10. Prescription drugs.

Marketplace Required Benefits

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Pediatric Benefits

Pediatric Vision – Covered at no

charge to children up to age 26.

• Vision Exams – one per year.

• Prescription Glasses (Frames and

Lenses) or Prescription Contacts

– one per year.

Pediatric Dental Coverage –

provided by standalone dental

carriers, not Molina.

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Non-Emergency Medical / Non-Medical Transportation:

Non Emergency Transportation is not covered across

all metal plans for 2017.

Transportation

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Cost Share

Similar to commercial plans, members covered under

Marketplace will have cost shares (a shared financial

responsibility). These include:

Co-Insurance

•Percentage of the cost of a procedure the member must pay.

Co-Payment

•Fixed dollar amount member pays for covered services.

Deductible

•Fixed dollar amount member must pay before insurance will pay.

First Dollar Coverage

•A set number of services where deductibles, co-insurance and co-payments are waived.

Out of Pocket Maximum (OOP Max)

•The maximum dollar amount of Cost Sharing that member will have to pay out of pocket for Covered Services in a calendar year. Cost Sharing includes payments towards Deductibles, Copayments, and Coinsurance.

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Annual Out of Pocket Maximum –

Embedded Approach:

For Individuals:

Total amount of Cost Sharing an individual

Member will have to pay for Covered

Services in a calendar year.

Cost Sharing includes payments made

towards any Deductibles, Copayments or

Coinsurance.

Once total Cost Sharing in a calendar

year reaches the specified individual

Annual Out-of-Pocket Maximum amount,

Molina will pay 100% of the charges for Covered Services for the remainder of the

calendar year.

Understanding Benefit Accruals

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*Amounts paid for services that are not Covered Services will not count towards the individual Annual Out-of-Pocket Maximum.


Embedded Approach:

For Family (2 or more Members):

Total amount of Cost Sharing that at least two or more

Members of a family will have to

pay for Covered Services in a

calendar year.

Cost Sharing includes payments

made towards any Deductibles,

Copayments or Coinsurance.


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Embedded Approach:

For Family (2 or more Members):

Once the total Cost Sharing

made by at least two or more

Members of a family reaches the

specified Annual Out-of-Pocket

Maximum amount, Molina will

pay 100% of the charges for

Covered Services for all enrolled

family Members for the

remainder of the calendar year.


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*Amounts paid for services that are not Covered Services under this Agreement will not count towards the family Annual Out-of-Pocket Maximum.

APTC vs. Non-APTC Members

APTC Member:

• Receives Advanced Premium Tax Credits

(premium subsidy).

Non-APTC Member:

• Members who are solely responsible for the

payment of the full monthly premium amount.

*For APTC members, the Grace Period is 3 months and 10 days for Non-APTC

members.

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Standard Grace Period – APTC Members

Pend Claims

For services received during the Months 2 &

3 of grace period

APTC Members Only

Provider Notification

When APTC member enters the grace

period

Claims for Months 2 & 3 may not be processed until the outstanding premium is received

Denied claims possible if all outstanding premium

due is not received by the end of the 3-month grace

period

If Member’s overdue premium is not

received at end of grace period

Member’s coverage will be terminated on last day of Month 1 of

Grace Period

Claims for services received during

Months 2 & 3 will be denied or recovered*

Member will be responsible for

payment of services received

In cases where the member has not paid their premium, the member is

placed into a Grace Period status and Molina will take the following steps,

as defined by ACA:

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*In the event that the APTC Member is terminated for non-payment of the full premium prior to the end of the grace period, Molina will retroactively deny Claims for services rendered in the second and third months of the grace period, and will issue a re-coup notice to the Provider(s) if appropriate.

Standard Grace Period – Non-APTC Members

Pend Claims

For services received during the Grace Period (10 Days)

Non-APTC Members Only

Provider Notification

When Non-APTC member enters the

grace period

Claims for Grace Period may not be processed until the outstanding premium is received

Denied claims possible if all outstanding premium

due is not received by the end of the 1-month Grace

Period

If Member’s overdue premium is not

received at end of grace period

Member’s coverage will be terminated on

last day of Grace Period

Member will be responsible for

payment of services received

In cases where the member has not paid their premium, the member is

placed into a Grace Period status and Molina will take the following steps,

as defined by ACA:

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Alerts

Whenever a member is in the grace period, Molina

Healthcare will have a service alert on the Web Portal, IVR and in the call

centers

The alert will provide more specific detail about

where the member is in the grace period

Providers should verify both the eligibility status AND any service alerts when

checking the eligibility of a Molina Healthcare

Marketplace member

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Member/Provider Notification of Grace Period

Members

• Notified upon entering of grace period.

Providers

• PCP’s and providers who have submitted claims during grace period.

• When member enters Month 2* of grace period.

Provider Notification Details

• **Services rendered during Months 2 & 3 of grace period may be denied or recovered.

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*1st Day of GP for Non-APTC Members **APTC Members only

If member submits payment and an outstanding balance exists

for 2016 premiums, then the payment received will be applied

toward that outstanding 2016 balance. The payment can not

be applied toward 2017 premium to renew the policy.

All payments must be applied to the oldest outstanding balance to avoid gaps in coverage.

Grace Period – Outstanding Balance

Grace Period Member – Web

Portal

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Member’s account will be flagged as Service Restricted

Under Enrollment

Information - Select “Service Restricted”

Grace Period Member – Web

Portal

42

Provider will see member’s specific Benefit

Restriction.

Provider Online Directory

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Directory Link: https://providersearch.molinahealthcare.com/Provider/ProviderSearch

?RedirectFrom=MolinaStaticWeb

https://providersearch.molinahealthcare.com/Provider/ProviderSearch?RedirectFrom=MolinaStaticWeb




Marketplace EOP – How to Identify?

How to Read Member EOB

Below are descriptions of the fields included on an EOB

Line – denoted which line of the claim the payment and remark information is for.

Some claims may contain multiple lines

Service Date – the date the services being billed were performed

Procedure Code – code number of the service that was performed

Billed Amount – amount of billed charges received from provider for service

rendered

Allowed Amount – the amount the health plan allows for service rendered

Copay Amount – the amount of member copay for certain benefits (i.e. office

visit, ER, etc.). This is a fixed dollar amount

Co-Insurance Amount – The percentage of the allowed amount owed by the member. In some cases, the deductible must first be satisfied before the

coinsurance is charged.

How to Read Member EOB

Below are descriptions of the fields included on an EOB

Deductible Amount – the amount a member must pay out of pocket before

Molina will pay for covered services. Deductible amounts vary by plan.

Plan Payment – the amount the health plan has paid to the provider

Remark Code – additional messages that may explain how claim was processed

under “Explanations of Claims Handling”

Total Patient Responsibility for This Claim – the amount the member is responsible

to pay to the provider

Description of Remark Code – explanation of the claim payment or denial

Family Out of Pocket & Deductible Totals – a summation of a family’s total yearly deductible amount and out of pocket amount based on benefits, the Year-to-

Date total that have been applied, and the remaining balances

General Pharmacy Information

• Preferred Drug Listing (PDL)

– http://www.molinahealthcare.com/providers/fl/

marketplace/drug/Pages/formulary.aspx

• Mail order is available (Tiers 1, 2, 3, and 5 only).

• Over-The-Counter (OTC) - There is currently no OTC

program available for Molina Marketplace

members.

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http://www.molinahealthcare.com/providers/fl/marketplace/drug/Pages/formulary.aspx



Requests for Authorization

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Providers may submit requests for prior authorization to the Utilization Management

Department in the following ways:

Web Portal : https://eportal.molinahealthcare.com/Provider/Login

Marketplace Fax: (866)-440-9791

If submitting via fax, please use the Service Request Form available online, at:

http://www.molinahealthcare.com/providers/fl/marketplace/forms/PDF/prior-

authorization-guide-2017.pdf

http://www.molinahealthcare.com/providers/fl/marketplace/forms/PDF/prior-authorization-guide-2017.pdf
















Claims

Providers may submit claims to Molina Healthcare on paper or electronically, using a current version CMS-1500, UB-04 or the electronic equivalent. Providers may also use our Web Portal to submit claims.

Medicaid/Marketplace Claims Submission Address Molina Healthcare of Florida P.O. Box 22812 Long Beach, CA 90801

Medicare Claims Submission Address

Molina Medicare P.O. Box 22811 Long Beach, CA 90801

EDI Claims Submission – Medicaid, Medicare & Marketplace Emdeon Payor ID# 51062

Emdeon Telephone (877) 469-3263

Web Portal https://eportal.molinahealthcare.com/Provider/Login

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F.S. 641.3155 requires that all Marketplace providers

submit all claims within six (6) months of the date of

service. Network providers must make every effort to

submit claims for payment in a timely manner, and

within the statutory requirement.

Corrected Claims may be submitted at any time

during the timely filing period of the provider

contract, or within 35 days of the claim Paid Date, if

the filing period has expired.

Timely Filing

Corrected Claims –

CMS-1500

• Box 22 – Use one of the following resubmission

codes:

• (7) Replacement of prior claim

• (8) Void/cancel of prior claim

• Box 22A (Original Ref No.) – Report the original claim number

• Loop 2300, CLM Segment, CLM05-3

(Claim Frequency Code) – Use one of

the following resubmission codes:

• (7) Replacement of prior claim

• (8) Void/cancel of prior claim

• Loop 2300 (REF Segment) – Report the

original claim number


837P (Electronic/Clearinghouse)

Providers must utilize the correct

Type of Bill Frequency Code to

indicate corrected claim.


UB04

Any disagreement regarding the processing, payment or non-payment of a claim is considered a Provider Dispute. To file a Provider Dispute, providers may contact Customer Service at (855) 322-4076, or send the request for review in writing, along with any supporting documentation to the address below:

Molina Healthcare of Florida Attn: Provider Disputes P.O. BOX 527450 Miami, FL 33152-7450 Fax: 877-553-6504

Provider Disputes must be received within one (1) year of the date of payment or denial of the claim. All provider disputes will be reviewed confidentially, and the outcome will be communicated in writing within sixty (60) days or receipt of the Provider Dispute. If the Provider Dispute results in an unfavorable decision, and the provider has additional documentation supporting their position, the provider may resubmit the Provider Dispute for secondary review. In the alternative, providers may also request a review of their original appeal

by the State’s independent dispute resolution organization, listed below:

Maximus Federal Services State Appeals Process 50 Square Drive Suite 120 Victor, NY 14564 Tel. (866) 763-6395 Fax (585) 425-5296

Provider Disputes

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http://www.molinahealthcare.com/members/fl/en-

US/mem/marketplace/coverd/Pages/allplans.aspx

Evidence Of Coverage (EOC)

Molina Healthcare of Florida’s Evidences Of Coverage are written

specifically to address the requirements of delivering healthcare

services to Molina Healthcare Marketplace members, including your responsibilities as a participating provider. Providers may

request printed copies of the respective Metal EOC’s, at no cost, by

contacting Provider Services at (855) 322-4076, or view them on our

website, at:

http://www.molinahealthcare.com/members/fl/en-US/mem/marketplace/coverd/Pages/allplans.aspx




Bronze Silver 100 Silver 150 Silver 200 Silver 250 Gold

Features (individual/family)

Medical Deductible $6,650/$13,3001

$0 $500/$10002 $2,275/$4,5502 $2,400/$4,8002 $1,025/$2,0502

Prescription Drug Deductible N/A N/A N/A N/A N/A

Annual Out-of-Pocket Maximum $7,150/$14,300 $1,250/$2,500 $2,250/$4,500 $5,700/$11,400 $7,150/$14,300 $7,150/$14,300

Benefits3

Emergency and Urgent Care Services

Emergency Room4 $350 copay ▲ $150 copay $205 copay $400 copay $400 copay $300 copay

Urgent Care $75 copay ▲ $15 copay $30 copay $60 copay $75 copay $60 copay

Outpatient Professional Services and Office Visits5

Preventive Care

No Charge Prenatal Visit

Well Child Visit

Family Planning

Primary Care $35 copay $0 copay $10 copay $20 copay $20 copay $15 copay

Specialty Care $80 copay ▲ $10 copay $30 copay $55 copay $55 copay $35 copay

Other Practitioner Care $35 copay $0 copay $10 copay $20 copay $20 copay $15 copay

Habilitative Care 40% coins ▲ 10% coins 20% coins 30% coins 30% coins 20% coins

Rehabilitative Care 40% coins ▲ 10% coins 20% coins 30% coins 30% coins 20% coins

Mental Health Services $35 copay $0 copay $10 copay $20 copay $20 copay $15 copay

Substance Abuse services $35 copay $0 copay $10 copay $20 copay $20 copay $15 copay

Pediatric Vision Services6

Vision Exam

No charge Glasses

Contacts ▲= Deductible Applies

1. Combined medical and pharmacy deductible (waived for preventive care, preventive drugs, generic drugs, hospice, primary care office visits, other practitioner office visits, mental health/substance abuse office visits).

4. This cost is waived if member is admitted directly to the hospital for inpatient services (refer to inpatient hospital services for applicable cost sharing information).

2. Medical deductible applies only to outpatient hospital / facility and inpatient hospital / facility services (does not apply to outpatient professional).

5. Some outpatient professional services not listed require coinsurance rather than a copayment. 6. Applicable to dependent children under age 19.

3. Certain benefits require prior authorization prior to obtaining services.

This "2017 Benefits-At-A-Glance" is intended to be a summary of covered benefits that lists some features of our plan. It does not list or describe all benefits covered under a specific product or every limitation or

exclusion.

Please consult the Agreement and Individual Evidence of Coverage for a detailed description of benefits, exclusions, and limitations.

Red lettering indicates changes from 2016 plan design

Molina 2017 Benefits At-A-Glance: RENEWAL PLANS

Outpatient Hospital / Facility

Services Bronze Silver 100 Silver 150 Silver 200 Silver 250 Gold

Laboratory Services $35 copay ▲ $10 copay $10 copay $35 copay $35 copay $15 copay

Radiology Services $80 copay ▲ $10 copay $30 copay $55 copay $55 copay $35 copay

Specialized Scanning Services

(CT, MRI, PET Scans) 40% coins ▲ 10% coins 20% coins ▲ 30% coins ▲ 30% coins ▲ 20% coins ▲

Medical/Surgical Services 40% coins ▲ 10% coins 20% coins ▲ 30% coins ▲ 30% coins ▲ 20% coins ▲

Inpatient Hospital Services

Medical/Surgical, Maternity Care,

Mental Health, Substance Abuse,

Skilled Nursing Facility

40% coins ▲ 10% coins 20% coins ▲ 30% coins ▲ 30% coins ▲ 20% coins ▲

Hospice Care No Charge

Prescription Drugs

Formulary Generic Drugs $33 copay $2 copay $5 copay $10 copay $10 copay $15 copay

Formulary Preferred Brand Drugs $65 copay ▲ $15 copay $30 copay $55 copay $55 copay $50 copay

Formulary Non-Preferred Brand

Drugs 50% coins ▲ 20% coins 30% coins 40% coins 40% coins 30% coins

Formulary Specialty Drugs 50% coins ▲ 20% coins 30% coins 40% coins 40% coins 30% coins

Ancillary Services

Durable Medical Equipment 40% coins ▲ 10% coins 20% coins 30% coins 30% coins 20% coins

Emergency Transportation -

Ambulance 40% coins ▲ 10% coins 20% coins 30% coins 30% coins 20% coins

Home Healthcare No Charge ▲ No Charge No Charge No Charge No Charge No Charge

Other Services

Dialysis $80 copay ▲ $10 copay $30 copay $55 copay $55 copay $35 copay

Supplemental Benefits

24-Hour Nurse Advice Line

No Charge

Weight control program

Motherhood Matters®, mothers-to-

be program

Tobacco counseling, smoking

cessation program ▲= Deductible Applies This "2017 Benefits-At-A-Glance" is intended to be a summary of covered benefits that lists some features of our plan. It does not list or describe all benefits covered under a specific product or every

limitation or exclusion.


Red lettering indicates changes from 2016 plan design

Molina 2017 Benefits At-A-Glance: RENEWAL PLANS

Molina 2017 Benefits At-A-Glance: NEW STANDARDIZED OPTION PLANS

Options

Bronze

Options Silver 100

Options Silver 150

Options Silver 200

Options Silver 250

Features (individual/family)

Medical Deductible $6,650/$13,3001

$250/$5002 $700/$14002 $3,000/$6,0002 $3,500/$7,0002

Prescription Drug Deductible N/A N/A N/A N/A

Annual Out-of-Pocket Maximum $7,150/$14,300 $1,250/$2,500 $2,000/$4,000 $5,700/$11,400 $7,150/$14,300

Benefits3

Emergency and Urgent Care Services

Emergency Room4 50% coins ▲ $100 copay ▲ $150 copay ▲ $300 copay ▲ $400 copay ▲

Urgent Care 50% coins ▲ $25 copay $40 copay $75 copay $75 copay

Outpatient Professional Services and Office Visits5

Preventive Care

No Charge Prenatal Visit

Well Child Visit

Family Planning

Primary Care

$45 copay or 50% coins ▲7 $5 copay $10 copay $30 copay $30 copay

Specialty Care 50% coins ▲ $10 copay $30 copay $55 copay $55 copay

Other Practitioner Care

$45 copay or 50% coins ▲7 $5 copay $10 copay $30 copay $30 copay

Habilitative Care 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Rehabilitative Care 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Mental Health Services $45 copay $5 copay $10 copay $30 copay $30 copay

Substance Abuse services $45 copay $5 copay $10 copay $30 copay $30 copay

Pediatric Vision Services6

Vision Exam

No charge Glasses

Contacts ▲= Deductible Applies

1. Combined medical and pharmacy deductible (waived for preventive care, preventive drugs, generic drugs, hospice, mental health/substance abuse office visits, and first three primary care/other practitioner office visits)

2. Medical deductible applies only to outpatient hospital / facility and inpatient hospital / facility services (does not apply to outpatient professional), emergency room, habilitative and rehabilitative services, radiology and lab services, durable medical equipment, emergency medical transportation (ambulance)

3. Certain benefits require prior authorization prior to obtaining services.

4. This cost is waived if member is admitted directly to the hospital for inpatient services (refer to inpatient hospital services for applicable cost sharing information).

5. Some outpatient professional services not listed require coinsurance rather than a copayment. 6. Applicable to dependent children under age 19. 7. For the first three primary care/other practitioner office visits, cost sharing is $45 copay with deductible waived.

After the first three visits, cost sharing is 50% coinsurance and is subject to deductible.

This "2017 Benefits-At-A-Glance" is intended to be a summary of covered benefits that lists some features of our plan. It does not list or describe all benefits covered under a specific product or every limitation or exclusion.


Outpatient Hospital / Facility Services Options Bronze

Options Silver 100

Options Silver 150

Options Silver 200

Options Silver 250

Laboratory Services 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Radiology Services 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Specialized Scanning Services (CT, MRI,

PET Scans) 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Medical/Surgical Services 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Inpatient Hospital Services

Medical/Surgical, Maternity Care, Mental

Health, Substance Abuse, Skilled Nursing

Facility

50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Hospice Care No Charge

Prescription Drugs

Formulary Generic Drugs $35 copay $3 copay $5 copay $10 copay $15 copay

Formulary Preferred Brand Drugs 35% coins ▲ $5 copay $25 copay $50 copay $50 copay

Formulary Non-Preferred Brand Drugs 40% coins ▲ $10 copay $50 copay $100 copay $100 copay Formulary Specialty Drugs 45% coins ▲ 25% coins 30% coins 40% coins 40% coins

Ancillary Services

Durable Medical Equipment 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Emergency Transportation - Ambulance 50% coins ▲ 5% coins ▲ 20% coins ▲ 20% coins ▲ 20% coins ▲

Home Healthcare No Charge ▲ No Charge No Charge No Charge No Charge

Other Services

Dialysis 50% coins ▲ $15 copay $25 copay $65 copay $65 copay

Supplemental Benefits

24-Hour Nurse Advice Line

No Charge

Weight control program

Motherhood Matters®, mothers-to-be

program

Tobacco counseling, smoking cessation

program ▲= Deductible Applies This "2017 Benefits-At-A-Glance" is intended to be a summary of covered benefits that lists some features of our plan. It does not list or describe all benefits covered under a specific product or every limitation or exclusion.


Molina 2017 Benefits At-A-Glance: NEW STANDARDIZED OPTION PLANS

Networks

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• Vision Service Plan (VSP)

• www.vsp.com

• Telephone: 800-615-1883 Vision

• Beacon Health Options

• www.beaconhealthoptions.com

• Telephone: 800-221-5487

Behavioral Health

• Quest Diagnostics

• www.questdiagnostics.com

• Telephone: 866-MYQUEST (866-697-8378)

Laboratory

• CVS Caremark

• www.caremark.com/wps/portal

• Telephone: 800-237-2767

Pharmacy Benefits

Manager

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THANK YOU!!!

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